EVIDENCE-BASED ANSWER
THE BEST INTERVENTION IS EDUCATION on proper positioning and attachment of the infant (strength of recommendation [SOR]: A, a systematic review of randomized controlled trials [RCTs]). No single topical preparation has been consistently demonstrated to be superior to others for relieving nipple pain (SOR: B, inconsistent RCTs).
Topical agents that show some evidence of benefit include expressed breast milk, lanolin, warm water compresses, tea bag compresses, hydrogel dressings, a chlorhexidinealcohol spray, and a polyethylene film dressing (SOR: B, inconsistent RCTs). Several studies found these interventions to be equivalent to basic breast care, including keeping the nipple clean and dry (SOR: B, RCTs).
One type of glycerin-based hydrogel dressing was associated with an increased incidence of breast infections (SOR: B, inconsistent RCTs).
Evidence summary
Nipple pain during the first week of breastfeeding is common. Some studies report a prevalence as high as 96%.1 Because nipple pain has been identified as an important factor in a woman’s decision to discontinue breastfeeding, preventing or treating it is important not only to increase individual women’s comfort but also to promote breastfeeding generally.
We identified 2 systematic reviews and 3 additional RCTs of interventions to treat or prevent nipple pain. Most studies included women serving as their own control, randomizing 1 breast to intervention and the other to control treatment. The remainder of the studies randomized women to either the intervention or control group. Major limitations of the studies included their generally small size and lack of blinding of participants to their treatment group. In only 1 study were the participants blinded.1,2
Women who receive education have less pain
Two studies of educational sessions, 1 antenatal (N=75) and 1 immediately postnatal (N=160), reported less nipple pain in the intervention groups (number needed to treat [NNT]=1.6 and 5.6, respectively). The antenatal education study demonstrated higher continuation of breastfeeding at 6 weeks postpartum in the intervention group (NNT=4.5), whereas the postnatal study showed no significant difference in continuation of breastfeeding in the intervention group at 6 weeks, 3 months, and 6 months.1
No one topical agent is superior
No single topical agent emerged as clearly superior to others for preventing or treating nipple pain. Warm water compresses have the most data to support their use: 2 trials showed superiority to other agents or no treatment, 3 trials demonstrated equivalence to other agents or no treatment, and no trial showed inferiority to other agents.